The purpose of this blog is purely educational. It does not advise any reader to forgo medical treatment for any condition. It describes methods that have not yet been proven effective through widespread scientific testing. Readers who are concerned about their health are advised to contact their physician.

Sunday, December 9, 2012

Iatrogenic disease - part 2

Oh my God. Oh ... my ... God. I am just reading a book, Dr. Marty Makary's Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Healthcare. Dr. Makary is a surgeon and an associate professor at Johns Hopkins. I can't put the book down. My blood pressure must be in the stratosphere. I am reading things that are making my hair stand on end.

Dr. Makary is scathingly honest about his profession. His candor burns like a cauterizing iron. In this book patients die; patients are maimed; mistakes are swept under the rug; surgeons who should never be allowed near patients continue to practice; professional bodies that are charged with overseeing doctors routinely fail to do so; and whistle-blowers who advocate for patients get fired or drummed out of the profession.

The scale of the problem is huge. In his introduction, and later in his chapter 8 (entitled "Impaired Physicians"), Dr. Makary writes of attending a conference where a renowned Harvard surgeon asked his audience if any of them had a colleague who they knew should not be performing surgery -- in an audience of thousands, every hand went up. He calculates that if only 2 per cent of America's doctors are impaired, that's 20,000 unsafe doctors, who altogether see about 10,000,000 patients a year. He calls this "a public health crisis".

As an intern at Harvard, Makary trained under a surgeon who was referred to behind his back as Dr. Hodad. "Hodad" stood for "Hands of Death and Destruction". Dr. Hodad had impeccable credentials, an unimpeachable presence, and a splendid bedside manner. His patients adored him and had no idea that his incompetence was the reason for their long hospital stays and their post-surgical complications.

Hospitals have no reason to rein in such surgeons, Makary tells the reader, because post-surgical complications add dollars to their coffers. The greater the number of procedures that need to be done, the longer a patient needs to stay, the more money a hospital makes: about $10,000 on average for each complication. Incompetence only becomes an issue if the patient who dies as a result is famous and the story gets wide-spread public airing, causing the hospital major embarrassment. There is a culture of omerta. Makary relates the story of a heart surgeon, one of four in a well-known hospital, who had "six consecutive deaths during routine bypass surgery". Soon after the sixth death, he was about to operate on yet another patient, when the patient asked the anasthesiologist, "Is my surgeon a good surgeon?" Thinking quickly on his feet, the anasthesiologist replied, "He is one of the four best heart surgeons we have here", and the patient luckily didn't ask how many there were. This young doctor was routinely protected by the other heart surgeons, who attributed the deaths of his patients to "extenuating patient circumstance".

Makary's point is that patients have no way of knowing whether they are in the hands of a competent doctor or a Dr. Hodad. Medical students who barely pass, or who have untreated substance abuse or psychiatric problems, also become doctors and receive a license to practice -- with little or no accountability. Doctors with known substance abuse problems may not be allowed to drive their cars, but they are still allowed to wield scalpels and prescribe potentially lethal drugs. Makary writes:
After we doctors graduate from medical school, the government, via state medical boards, pretty much gives us a pass to do whatever we want.... After ... I got my license based on a 70-per-cent-or-higher passing score on my board exam, I was literally licensed to do anything in medicine -- perform brain surgery, prescribe chemotherapy, remove varicose veins, or do electric-shock therapy for psychiatric disorders ... I can legally do anything.
The issue is not only a small percentage of incompetent physicians, but also the "Wild West" attitude endemic in the culture and practice of medicine. Much has been written about the conditions under which young doctors are trained: brutal work hours; little sleep; inadequate support; even psychological abuse. The conditions are such that it is often impossible for them to deliver even adequate care. Makary writes about one night when he was an intern at D.C. General Hospital, trying to handle twelve emergency cases all at once. He called his chief resident for help and got shouted at for his pains. He then did his best on his own, with the help of a medical student, but two of the patients died. He mentions other cases where patients died because the intern on duty was spread too thin. So when he also cites a study claiming that one in four hospitalized patients experience some kind of harm due to medical error, the surprise is not that the number is so high, but that it is so low.

Makary quit his medical training after one of his own patients came to grief despite his best efforts to prevent her having the entirely unnecessary procedure that harmed her. He says:
I felt disillusioned. It seemed as if, despite all the book knowledge I had gained, nearly half of the patients I saw in the clinics had problems for which modern medicine had nothing to offer except phony names for diseases we didn't understand. The other half .... seemed to be sick because they were obese, smoking or not taking care of themselves -- preventable problems.
He switched to the Harvard School of Public Health, where he learned a whole new perspective on disease, and later returned to medicine because he missed the contact with patients, resolving to practice medicine as he thought "it ought to be practiced -- with honesty".

The economic angle

The book also takes aim at the business model of medicine, in which doctors are encouraged to perform ever more procedures to generate income for the hospital, and in which the CEOs of children's hospitals are compensated to the tune of millions of dollars. As an example of the business attitude that pervades healthcare he quotes an email sent by a hospital administrator to the surgeons in his department, which reads, "As we approach the end of the fiscal year, try to do more operations. Your productivity will be used to determine your bonus." He points out that doctors and hospitals profit from prescribing chemotherapy, that doctors receive commissions, royalties and consulting fees from using prosthetics and surgical implants. Between paying for errors, unnecessary procedures, and excessive compensation under what Makary calls the "eat what you kill" model, it is little wonder that the U.S. is staggering under the costs of delivering healthcare to its citizens.

Parts of the book deal with solutions, which is just as well, because otherwise it would be an infuriating and depressing read. The larger perspective Makary attained at the Harvard School of Public Health allows him to provide suggestions for systemic improvement. He advocates salaries for doctors rather than payment per procedure; transparency about patient outcomes; public access to information; changing the workplace culture of hospitals to privilege teamwork over hierarchy and safety over profit. He especially highlights the importance of teamwork: in the interest of patient safety, everyone who works at the hospital, regardless of where they are in the hierarchy, should be able to speak up, just as anyone on the Honda assembly line is allowed to shut it down if they spot a problem.

After lambasting his profession for most of the book, Makary reveals at the end that he is optimistic about the future. The culture is changing; the medical students he now works with are more into openness and honesty with patients and are less willing to put up with hazing and shenanigans than his generation was. New technologies such as interactive patient records and video cameras in the operating rooms aid transparency. The internet has revolutionized the ability of patients to obtain information so they can ask more knowledgeable questions. There is a light at the end of the tunnel. My blood pressure back to normal, I was pleased to read that the new generation of medical students is open even to alternative therapies.

And in the meantime, until the system is thoroughly reformed, Dr. Makary offers patients a list of questions to ask their doctors on his website,

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